Mentalizing Mediates the Association between Narcissism and Psychotherapeutic Treatment Outcome in a Mixed Clinical Sample.

INTRODUCTION: Pathological narcissism has been a challenge for the success of psychological treatment, whereas mentalizing has turned out to be an important mechanism of change in psychotherapy. This study focused on the classic narcissistic self (CNS) (i.e., narcissistic grandiosity) as predictor of the outcome. It further investigated whether mentalizing mediates this relation. METHODS: A mixed clinical sample of 205 patients was investigated. The CNS scale of the Narcissism Inventory and the Mentalization Questionnaire was used to measure the features of narcissistic grandiosity and the capacity to mentalize, respectively. The symptom outcome was assessed with the Hamburg Modules for the Assessment of Psychosocial Health. RESULTS: Contrary to our expectations, we did not find a direct association between narcissistic grandiosity and a decrease in symptoms. However, mentalizing was found to mediate the association between the CNS as well as between the narcissistic furor and outcome. CONCLUSION: Our results confirm the ambiguity concerning the clinical significance of narcissistic grandiosity. However, in order to improve the treatment outcome in patients with narcissistic features, especially narcissistic furor, individualized treatment plans might consider introducing interventions that enhance the capacity to mentalize.

Psychometric evaluation of the German version of the Brief Reflective Functioning Interview.

OBJECTIVES: To measure mentalization in a feasible manner, various instruments have been designed in recent years. The Brief Reflective Functioning Interview (BRFI) is a short interview that is based on the Adult Attachment Interview (AAI). The aim of both studies was to examine the psychometric properties of the German version of the BRFI and to compare them to those of the AAI. METHODS: In Study 1, we examined 60 students using the BRFI and the AAI. In Study 2, the validity of the BRFI was examined using a mixed sample of students and patients (N = 149). Trained coders evaluated the Reflective Functioning Scale (RFS) for the BRFI and the AAI. RESULTS: We found a significant positive correlation between the RFS total scores of the BRFI and those of the AAI. In addition, both interviews showed excellent internal consistency. We could also show that persons with mental disorders exhibit lower levels of RF score than mentally stable individuals. Women had higher RF scores in the BRFI than men in both samples. Persons whose mentalization capacity was rated below average in either the BRFI or the AAI also reported significantly lower mentalization ability in the self-assessment (p < .01). CONCLUSIONS: Our results revealed that the RFS scores measured by the BRFI are highly comparable to those measured by the AAI. Our findings support the results of previous studies, suggesting that the BRFI is a reliable, valid and easy-to-administer alternative to the AAI. PRACTITIONER POINTS: The German version of the Brief Reflective Functioning Interview (BRFI) proved to be a reliable and valid instrument for the assessment of reflective functioning that is shorter in terms of time to complete and the evaluation process than the measurement via the Adult Attachment Interview (AAI). Reflective functioning is negatively associated with psychopathology.

Incidence and risk factors of mental disorders in the elderly: The European MentDis_ICF65+ study.

OBJECTIVE: While incidence rates of depression and anxiety disorders in the elderly have been comprehensively investigated, the incidence rates of other mental disorders have rarely been researched. The incidence rate and predictors of various mental disorders in the elderly were evaluated in different European and associated countries. METHODS: A cross-sectional and longitudinal multi-centre survey of Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnoses was conducted in different European and associated countries (Germany, Italy, Spain, Switzerland, the United Kingdom and Israel) to collect data on the prevalence and incidence of mental disorders in the elderly. The sample size of the longitudinal wave was N = 2592 elderly. RESULTS: The overall 1-year incidence rate for any mental disorder in the elderly is 8.65%. At 5.18%, any anxiety disorder had the highest incidence rate across all diagnostic groups. The incidence rate for any affective disorder was 2.97%. The lowest incidence rates were found for agoraphobia (1.37%) and panic disorder (1.30%). Risk factors for the development of any mental disorder were never having been married, no religious affiliation, a higher number of physical illnesses and a lower quality of life. CONCLUSION: In comparison to other studies, lower incidence rates for any affective disorder and middle-range incidence for any anxiety disorder were found. To the authors' knowledge, no prior studies have reported 1-year incidence rates for somatoform disorder, bipolar disorder and substance misuse in community-dwelling elderly. These findings indicate the need to raise awareness of psychosocial problems in the elderly and to ensure adequate availability of mental health services.

Increasing Mentalization to Reduce Maladaptive Defense in Patients With Mental Disorders.

Background: There are indications of associations between the ability to mentalize and psychological defense mechanisms. However, only a few studies have focused on these associations, and even fewer have included empirical analyses. In the present study, we aimed to fill this research gap by analyzing the link between the ability to mentalize and psychological defense mechanisms in patients with mental disorders. We examined whether changes in defense mechanisms are predicted by an increase in mentalization or whether such changes are only related to reductions in psychopathology and interpersonal problems. Methods: A clinical sample of N = 89 patients was studied during and after inpatient psychiatric rehabilitation. Repeated-measures analyses of variance were performed to determine changes in mentalization, psychological defense, psychopathology, and interpersonal problems over the course of therapy and post-treatment. Linear regression analyses were used to predict the change in defense patterns based on an increase in mentalization. Results: Maladaptive defense mechanisms were significantly reduced during inpatient therapy and remained low until follow-up, whereas neurotic and adaptive defense mechanisms did not change significantly. The results of the regression analyses indicated that mentalization played an important role in the reduction in maladaptive defense during and after inpatient rehabilitation for mental disorders, whereas reductions in psychopathology and interpersonal distress were only partially associated with a reduction in maladaptive defense. Conclusion: We conclude that mentalization is vital for reducing maladaptive defense mechanisms, which are commonly associated with mental disorders. In therapy, an increase in patients' capacity to mentalize may be a practicable approach to diminish maladaptive defense mechanisms.

Quality of life, level of functioning, and its relationship with mental and physical disorders in the elderly: results from the MentDis_ICF65+ study.

BACKGROUND: An ageing population worldwide needs to investigate quality of life (QoL) and level of functioning (LoF) in the elderly and its associated variables. We aimed to study the relationship between Quality of Life (QoL) and Level of Functioning (LoF) in an elderly population in Europe. METHOD: As part of the Ment_Dis65+ European Project, 3142 community-dwelling adults aged 65-84 years in six countries were assessed by using the adaptation for the elderly of the Composite International Diagnostic Interview (CIDI65+) to provide psychiatric diagnosis according to the International Classification of Diseases (10th edition) (ICD-10 Classification of Mental and Behavioural Disorders). Socio-demographic and clinical interviews, and two self-report tools, the World Health Organization QoL assessment (WHO QoL BREF), to assess QoL, and the WHO Disability Assessment Schedule -II (WHODAS-II), to assess LoF, were also administered. RESULTS: Most subjects reported good levels of QoL (56.6%) and self-rated health (62%), with no or mild disability (58.8%). There was a linear decrease of the QoL and the LoF by increase of age. Elderly with ICD-10 mental disorder (e.g. somatoform, affective and anxiety disorders) had poorer QoL and lower LoF. There were a number of predictors of lower levels of QoL and disability, including both socio-demographic variables (e.g. male gender, increase in age, poor financial situation, retirement, reduced number of close significant others), ICD-10 psychiatric diagnosis (mainly anxiety, somatoform disorders) and presence of medical disorders (mainly heart and respiratory diseases). CONCLUSIONS: The study indicates that QoL and LoF were quite acceptable in European elderly people. A series of variables, including psychiatric and somatic disorders, as well as socio-demographic factor influenced in a negative way both QoL and LoF. More specific links between mental health, social and health services dedicated to this segment of the population, should be implemented in order to provide better care for elderly people with conditions impacting their QoL and functioning.

Affective disorders in the elderly in different European countries: Results from the MentDis_ICF65+ study.

OBJECTIVES: Affective disorders are among the most prevalent disorders in the elderly. The present study aims to examine the sociodemographic and clinical correlates of major depressive disorder (MDD) and dysthymia in different European and Associated countries using standardized interview techniques. Furthermore, service utilization for the elderly with depression is assessed. METHODS: The MentDis_ICF65+ study is a cross-sectional survey (N = 3,142) that was conducted in six different European and Associated countries (Germany, Italy, Spain, Switzerland, England and Israel) with a subsample of n = 463 elderly with any depressive disorder. RESULTS: Sociodemographic and clinical correlates, such as gender, age and symptom severity, were significantly associated with MDD and dysthymia in the elderly. Only 50% of elderly with any depressive disorder were treated with psycho- or pharmacotherapy. CONCLUSION: Our findings identified sociodemographic and clinical characteristics for depression risk in the elderly and highlight the need to improve service delivery to older adults who suffer from depression.

The role of meaning in life in community-dwelling older adults with depression and relationship to other risk factors.

OBJECTIVES: The aims of this study were to examine the association of Meaning in Life (MiL) with sociodemographic and physical factors, and its association with depression in older people. METHOD: A cross-sectional survey with a sample of N = 2104 older adults from communities of four European countries was conducted, using an age-appropriate interview for the diagnosis of depression and the Schedule for Meaning in Life Evaluation (SMiLE) questionnaire to assess MiL. RESULTS: Overall, MiL was particularly low in old male participants, in older people from Ferrara (Italy), those with a lower religious affiliation, fewer social contacts, and poorer physical health. Furthermore, younger old age (65-69 compared to 80-84 year olds), female gender, being married, living in Geneva and poorer physical health were significantly associated with a higher risk for depression. In addition, lower MiL significantly increased the likelihood to suffer from depression in older people. An interaction effect of study center and MiL also emerged: with decreasing MiL the risk for depression significantly increases in Hamburg compared to the other study centers. CONCLUSION: This study underlines the association of MiL and depression in old age. Integration of meaning-specific aspects in treatment for older adults with depression may be promising.

Alcohol use, abuse and dependence in an older European population: Results from the MentDis_ICF65+ study.

BACKGROUND: Alcohol use disorders (AUD) in older people have been the subject of increasing interest in Europe and worldwide. However, thus far, no reliable data exist regarding the prevalence of AUD in people over the age of 65 years in Europe. OBJECTIVE: To assess the current (past month), 12-month and lifetime prevalence of alcohol use, abuse and dependence in people aged 65-84 years. STUDY DESIGN: The MentDis_ICF65+ study was a representative stepwise cross-sectional survey that was conducted in six European and associated cities (Hamburg, Germany; Ferrara, Italy; London/Canterbury, England; Madrid, Spain; Geneva, Switzerland and Jerusalem, Israel). METHOD: In total, 3,142 community-dwelling people aged between 65 and 84 years who lived in participating cities were assessed with an age-sensitive diagnostic interview (CIDI65+). RESULTS: The prevalence of lifetime alcohol use was 81% for the overall sample. The observed AUD (DSM-IV-TR) prevalence was as follows: current, 1.1%; 12-month, 5.3% and lifetime, 8.8%. Alcohol consumption and AUD were more prevalent in males, and a significant interaction between gender and city was observed; greater gender differences in the prevalence of these disorders were observed in Hamburg, London/Canterbury and Geneva in comparison to the other cities. The prevalence of lifetime alcohol consumption and 12-month AUD tended to be lower in older persons. CONCLUSION: The results highlight the appropriateness of using age-adjusted diagnostic tools (CIDI65+) to identify alcohol use and AUD in older people. Different alcohol use patterns were observed in males and females. The results seem to indicate the presence of different alcohol use patterns between northern and southern European countries. Specialized services are proposed, including brief and/or more intensive interventions framed intensive and more simple interventions framed in stepped care strategies, to improve the social and health resources available for older people across Europe.

Mentalization and Self-Efficacy as Mediators between Psychological Symptom Severity and Disabilities in Activities and Participation in Psychotherapy Patients.

BACKGROUND: Psychotherapy patients can be more or less disabled by their psychological symptoms. The present study investigated whether mentalization and self-efficacy contribute to the association between psychological symptom severity and disabilities in activities and participation. METHODS: The data of 216 psychotherapy inpatients were examined in a cross-sectional design. Bootstrapping-enhanced mediation analyses were performed to investigate whether self-efficacy and mentalization are mediators between psychological symptom severity and disabilities in activities and participation. The Hamburg Modules for the Assessment of Psychosocial Health-49 were used to measure psychological symptom severity and self-efficacy, mentalization was assessed with the Mentalization Questionnaire, and disabilities in activities and participation were operationalized with the ICF-Mental-A & P questionnaire. RESULTS: Mentalization as well as self-efficacy functioned as mediators between psychological symptom severity and disabilities in activities and participation (p < 0.05). They were equally strong mediators, and both remained significant mediators when statistically controlling for the other mediator (p < 0.05). CONCLUSIONS: Mentalization as well as self-efficacy explain a significant proportion of the relationship between psychological symptom severity and disabilities in activities and participation. Working on mentalizing and self-efficacy might be important mechanisms to reduce disability due to symptoms. The cross-sectional design is a limitation of the study.

Predisposing, enabling, and need factors of service utilization in the elderly with mental health problems.

ABSTRACTBackground:Empirical data on the use of services due to mental health problems in older adults in Europe is lacking. The objective of this study is to identify factors associated with service utilization in the elderly. METHODS: As part of the MentDis_ICF65+ study, N = 3,142 people aged 65-84 living in the community in six European and associated countries were interviewed. Based on Andersen's behavioral model predisposing, enabling, and need factors were analyzed with logistic regression analyses. RESULTS: Overall, 7% of elderly and 11% of those with a mental disorder had used a service due to mental health problems in the last 12 months. Factors significantly associated with underuse were male sex, lower education, living in the London catchment area, higher functional impairment and more comorbid mental disorders. The most frequently reported barrier to service use was personal beliefs, e.g. "I can deal with my problem on my own" (90%). CONCLUSION: Underutilization of mental health services among older people in the European community is common and interventions are needed to achieve an adequate use of services.

Anxiety Disorders in Old Age: Psychiatric Comorbidities, Quality of Life, and Prevalence According to Age, Gender, and Country.

OBJECTIVES: Previous estimates of the prevalence of anxiety disorders in late life vary greatly due to the lack of reliable diagnostic tools. This MentDis_ICF65+ study assessed 12-month prevalence rates of anxiety disorders and age- and gender-related differences in comorbidities, as well as impact on quality of life. DESIGN: The study used a cross-sectional multicenter survey. PARTICIPANTS: The study sample comprised 3,142 men and women aged 65 to 84 years, living in five European countries and Israel. MEASUREMENTS: Anxiety disorders were assessed using computer-assisted face-to-face interviews with an age-appropriate diagnostic interview (CIDI65+). RESULTS: The prevalence of anxiety disorders was 17.2%. Agoraphobia was the most frequent disorder (4.9%), followed by panic disorder (3.8%), animal phobia (3.5%), general anxiety disorder (3.1%), post-traumatic stress disorder (1.4%), social phobia (1.3%), and obsessive-compulsive disorder (0.8%). The prevalence rate of any anxiety disorder dropped by 40% to 47% in adults aged 75-84 years compared with those aged 65-74 years. Women were twice as likely to present with agoraphobia or general anxiety disorder as men. Only panic disorder and phobia were associated with comorbid major depression. The negative relationship with quality of life was limited to agoraphobia and generalized anxiety disorder. CONCLUSIONS: The age-appropriate CIDI65+ led to higher prevalence rates of anxiety disorders in the elderly, yet to weaker associations with comorbidities and impaired quality of life compared with previous studies.

Study approach and field work procedures of the MentDis_ICF65+ project on the prevalence of mental disorders in the older adult European population.

BACKGROUND: This study describes the study approach and field procedures of the MentDis_ICF65+ study, which aims to assess the prevalence of mental disorders in older adults. METHODS: An age-appropriate version of the Composite International Diagnostic Interview (CIDI65+) was developed and tested with regard to its feasibility and psychometric properties in a pre-test and pilot phase. In the cross-sectional survey an age-stratified, random sample of older adults (65-84 years) living in selected catchment areas of five European countries and Israel was recruited. RESULTS: N = 3142 participants (mean age 73.7 years, 50.7% female) took part in face-to-face interviews. The mean response rate was 20% and varied significantly between centres, age and gender groups. Sociodemographic differences between the study centres appeared for the place of birth, number of grandchildren, close significants, retirement and self-rated financial situation. The comparison of the MentDis_ICF65+ sample with the catchment area and country population of the study centres revealed significant differences, although most of these were numerically small. CONCLUSIONS: The study will generate new information on the prevalence of common mental disorders among older adults across Europe using an age-appropriate, standardized diagnostic instrument and a harmonized approach to sampling. Generalizability of the findings and a potentially limited representativeness are discussed.

Prevalence and correlates of somatoform disorders in the elderly: Results of a European study.

Somatoform disorders have rarely been addressed in epidemiological and health care services studies of the elderly. The few existing studies vary considerably in their methodologies limiting comparability of findings. Data come from the MentDis_ICF65+ study, in which a total of 3142 community-dwelling respondents aged 65-84 years from six different countries were assessed by the Composite International Diagnostic Interview adapted to the needs of the elderly (CIDI65+). The 12-month prevalence rate for any somatoform disorders was found to be 3.8, whereby the prevalence for somatization disorder according to DSM-IV was 0%, the prevalence for abridged somatization was 1.7% and the rate for 12-months somatoform pain disorder was 2.6%. We found a significant variation by study centre (p < 0.005). There was a significant gender difference for pain disorder, but not for abridged somatization. Significant age-related effects revealed for both disorder groups. Somatoform disorders were found to be associated with other mental disorders [odds ratio (OR) anxiety =4.8, OR affective disorders 3.6], as well as with several impairments and disabilities. Somatoform disorders are prevalent, highly impairing conditions in older adults, which are often associated with other mental disorders and should receive more research and clinical attention.

Prevalence of mental disorders in elderly people: the European MentDis_ICF65+ study.

BACKGROUND: Except for dementia and depression, little is known about common mental disorders in elderly people. AIMS: To estimate current, 12-month and lifetime prevalence rates of mental disorders in different European and associated countries using a standardised diagnostic interview adapted to measure the cognitive needs of elderly people. METHOD: The MentDis_ICF65+ study is based on an age-stratified, random sample of 3142 older men and women (65-84 years) living in selected catchment community areas of participating countries. RESULTS: One in two individuals had experienced a mental disorder in their lifetime, one in three within the past year and nearly one in four currently had a mental disorder. The most prevalent disorders were anxiety disorders, followed by affective and substance-related disorders. CONCLUSIONS: Compared with previous studies we found substantially higher prevalence rates for most mental disorders. These findings underscore the need for improving diagnostic assessments adapted to the cognitive capacity of elderly people. There is a need to raise awareness of psychosocial problems in elderly people and to deliver high-quality mental health services to these individuals.

Measuring symptoms and diagnosing mental disorders in the elderly community: the test-retest reliability of the CIDI65.

UNLABELLED: Prevalence findings for the elderly are artificially low, most likely due to insufficient consideration of age-related cognitive abilities in diagnostic interviews. AIMS: (1) To describe the rationale for the development of an age-adapted Composite International Diagnostic Interview (CIDI65+) for use in a European project (MentDis_ICF65+). (2) To examine its test-retest reliability. METHODS: Based on substantive pilot work the CIDI standard questions were shortened, broken down into shorter subsets and combined with sensitization questions and dimensional measures. Test-retest was determined in N = 68 subjects aged 60-79 years via two independent examinations by clinical interviewers using kappa (sensitivity, specificity) for categorical and intraclass correlation (ICC) coefficients for dimensional measures. RESULTS: Test-retest reliability was good for any mental disorder (κ = 0.63), major depression (κ = 0.55), anxiety (κ = 0.62, range = 0.30-0.78), substance (κ = 0.77, range = 0.71-0.82), obsessive-compulsive disorder (κ = 1.00) and most core symptoms/syndromes (κ range = 0.48-1.00). Agreement for some disorders (i.e. somatoform/pain) attenuated, partly due to time lapse effects. ICC for age of onset, recency, quantity, frequency and duration questions ranged between κ = 0.60-0.90. Dimensional agreement measures were not consistently higher. CONCLUSION: The age-adapted CIDI65+ is reliable for assessing most mental disorders, distress, impairment and time-related information in the elderly, prompting the need to examine validity.